4 physical problems ISTDP can treat

Intensive short-term dynamic psychotherapy (ISTDP) and other brief or short-term dynamic therapy models have a growing research base for the treatment of medically-unexplained physical problems. Here are 4 specific conditions for which there is an empirical evidence base:

Pelvic pain/ urethral syndrome—Pelvic or urinary pain in the absence of a physical injury or abnormality can have roots in unconscious emotional processes, especially from anxiety shunted into the smooth muscles of the urogenital system (see Abbass, 2015). Baldoni, et al. (1995) at the University of Bologna, Italy utilized ISTDP (e.g., Davanloo, 1990) in a randomized-controlled trial to address medically-unexplained urethral syndrome and pelvic pain. They found no significant improvement in the control group, who were treated with traditional urological therapies, and found that 70% of the people in the group that received ISTDP remained symptom free at 6 months and 4 years follow-up.

Irritable Bowel Syndrome (IBS)—Both Guthrie (1993) and Creed (2003) completed randomized, controlled trials of short-term psychodynamic therapies (STPP) for irritable bowel syndrome, both of which demonstrated efficacy of STPP for IBS. People with IBS have also been included in ISTDP studies of naturalistic case series data that suggested that ISTDP can be useful in the treatment of IBS (e.g., Abbass, 2002).

Psychogenic movement disorders—Psychogenic movement disorders (PMD) include tremors, rigidity, twitches, tics, and muscle weakness that are linked with underlying emotional factors, including anxiety, conversion, and somatization. Hinson, et al. (2006) used ISTDP (e.g., Davanloo, 2000) in a clinical trial for psychogenic movement disorders and found that ISTDP, with appropriate use of medications, can be a suitable treatment for PMD.

Headache—Barnat (1981) utilized a brief treatment course of brief dynamic therapy in an uncontrolled case series that yielded 75.6% symptom improvement in a group of people with treatment-refractory headache. People with migraine have also been included in ISTDP studies of naturalistic case series data that suggested that ISTDP can be useful in the treatment of migraine (e.g., Abbass, 2002).

Reflections on the current research base

This research base of short-term dynamic therapies for physical symptoms is exciting, but has many limitations and leaves unanswered questions. Savvy consumers of research will look at the above data with a realistically skeptical stance—the evidence base for these specific disorders is not ideally robust. The evidence base discussed here is not totally exhaustive, and more studies are coming out regularly, but we definitely require more studies of ISTDP and other STPPs that are specific to these medical diagnoses.

Medically-unexplained symptoms

There is, however, a growing body of evidence that ISTDP is an effective (e.g., Abbass, et al., 2009), cost-effective (Abbass & Katzman, 2013) treatment for a variety of medically-unexplained physical symptoms (MUS)—physical problems that are associated with underlying emotional factors.

While the MUS literature contains heterogenous samples with a wide variety of medical diagnoses, the studies indicate that ISTDP may be effective in reducing symptoms and repeated medical service use in the treatment of MUS generally.

In addition to the empirical data on the 4 conditions above and on MUS in general, my clinical experience working with people with IBS, migraines, pseudoneurological symptoms (e.g., tingling and numbness, blurry vision), muscle weakness, phantom itches, chronic fatigue, and chronic pain conditions has convinced me that ISTDP can be useful in the treatment of medically-unexplained physical symptoms. If you are struggling with medical symptoms that have not responded to treatments, and if medical tests have proven inconclusive, I invite you to examine the evidence for yourself and decide whether a trial therapy of ISTDP is the right choice for you. Feel free to reach out to us if you have any questions.

References

Abbass, A. (2002) Office based research in ISTDP: Data from the first 6 years of practice. Ad Hoc Bulletin of Short-term Dynamic Psychotherapy, 6, 5-14.

Interesting review. Thank you for sharing. One question that I have is related to the competence standard of the APA ethics code. In case ISTDP is practiced by a psychologist, not a psychiatrist, is he or she qualified and competent to differentially diagnose migraine from cluster headache from reflected pain? Would he or she be practicing outside the area of competence, if client’s presenting problem is headache, not a mental disorder overtly stated? An exact etiology of migraine and many other types of headache is not known. It would be an inference to attribute psychogenic nature to migraine’s etiology. How will the psychologist evaluate medical risks associated with taking on patients, who have pain as the main presenting problem without medics working in parallel? Finally, is it adequate for a psychologist to claim that he or she “specialise” in headaches or “medically unexplained” conditions? What is and what is not within the area of competence of an ISTDP clinician, who does not have medical training?

Thanks for your important questions, Alexey. I have copy and pasted your questions and responded.

In case ISTDP is practiced by a psychologist, not a psychiatrist, is he or she qualified and competent to differentially diagnose migraine from cluster headache from reflected pain?

I do not diagnose the specific nature of the headache. That diagnosis is often rendered by the referring physician with specific competence in that area. What ISTDP method of assessment and interventions help us to differential diagnose is whether and to what degree the headache is driven by emotional factors—e.g., does the migraine pop up as we explore certain feelings and thoughts.

Would he or she be practicing outside the area of competence, if client’s presenting problem is headache, not a mental disorder overtly stated?

Great question. Sometimes folks come in with a psychiatric diagnosis of somatic symptom disorder. Other times, they are struggling with emotional difficulties like anxiety or depression, and migraine, IBS, or pain symptoms are additional concerns. Either way, if the headache is driven by emotional factors, and psychological interventions provide relief, I think it is within the realm of competence. I’m open to your thoughts about that in interpreting the ethics code.

It would be an inference to attribute psychogenic nature to migraine’s etiology.

Yes it would be. We can only see if there is a link between emotions and migraine via exploration and moment-by-moment assessment, and consensus with the person we’re trying to help, not based on assumptions about its origins.

How will the psychologist evaluate medical risks associated with taking on patients, who have pain as the main presenting problem without medics working in parallel?

We always collaborate with referring physicians. Often they refer to us because they recognize that the person’s needs are outside the realm of their competence; that is, the symptom is linked with stress and emotions, and not responding to medical interventions. In ISTDP training, we also learn skills for assessing and building affect tolerance, and we grade our interventions carefully to the tolerance of the person we’re working with. This can be a safeguard against the risk of symptom exacerbation.

What is and what is not within the area of competence of an ISTDP clinician, who does not have medical training?

I think the same rules apply to ISTDP clinicians that apply to all clinicians—do not operate outside an area where you have specific training. In ISTDP training, there is a major focus on psychophysiology which helps clinicians in their assessment of somatic experience of emotions. Our area of competence is in collaborating with people to assess of whether there is a link between activation of emotions and symptoms, and then assisting people to overcome their body’s involuntary response (e.g., stomach ache, headache) to emotional activation. It is an research question whether medical training beyond what we get in ISTDP training would improve outcomes and reduce risk.